205 / 330
205
19–22 APRIL, 2017, BARCELONA, SPAIN
16:56–16:59
S19-4 (PP)
EVALUATING EFFECTS OF THREATS AND TEAM EFFICACY
ON EFFICIENCY IN A PEDIATRIC UROLOGY OPERATING
ROOM
Jessica M MING
1
, Michael E CHUA
1
, Fadi ZU’BI
1
, Eric PHAM-HUNG
2
, Bisma AMIR
1
,
Edward HICKEY
2
and Martin A KOYLE
1
1) Hospital for Sick Children, Urology, Toronto, CANADA - 2) Hospital for Sick Children, Cardiovascular Surgery, Toronto,
CANADA
PURPOSE
Minor threats and errors in the operating room (OR) can lead to harmful complications in patient
safety as well as decreased efficiency in relatively straightforward operations. We implemented the
aviation industry’s “threat and error” management model to patients’ operations. Our aim was to
increase the identification of systemic threats and associated errors within pediatric urology operat-
ing room by using “line operating safety audits” (LOSA).
MATERIAL AND METHODS
After QI committee approval, 75 inguinal-srotal, penile and laparoscopic cases were prospectively
observed by 2 independent observers. LOSAevaluation forms assessed 3 phases:I - wheels in- first
incision, II - incision- last stitch, III - final stitch- wheels out. From this, two independent observers
assessed: time vs. delay and number of threats per case (co-morbidities, equipment failure, distrac-
tion, sterility, failure of communication) using LOSA evaluation forms. The Oxford NOTECH II rating
system was used to evaluate the non-technical skills of the OR teams (surgical, anesthetic and
nursing). Data was tabulated and assessed for downstream errors or correlation to OR efficiency.
RESULTS
Mean number of threats per penile or scrotal case was 2.71+2.1 and 1.64+1.4, while for lapa-
roscopic cases mean number of threats was 7.5+3.5. We found no correlation between number
of threats and delays to the OR or to the phase in which these threats occurred. No significant
errors resulted from these threats amongst the cases observed. Amongst the two observers, mean
NOTECH scores in phase I, II and III were 73.7+2.5, 73.9+2.7, and 73.0+2.1.
CONCLUSIONS
Due to short OR times and few complications (harm) identified, threats relating to OR efficiency
were not identified. Patient safety and teamwork were consistently maintained according to the
NOTECH scoring results. We next plan to evaluate how team performance affects overall patient
outcomes (length of stay, complications, and OR throughput).
16:59–17:11
Discussion